From despondency to optimism: 25 years of HIV in India

The YRG Centre for AIDS Research and Education, Chennai, recently organized with partners the Chennai ART Symposium (CART 2012), and The International Science Symposium on HIV and Infectious Diseases, to deliberate upon a wide range of aspects related to HIV infection and provide latest clinical updates on the management of the disease, which has been plaguing the Indian populace for over 25 years.
The first case of HIV/AIDS in India was detected in the sex workers of Chennai in 1986. It was a kind of shocking disbelief, which ultimately transformed into panic and then hopeless resignation. According to Dr Ramesh Paranjape, Director National AIDS Research Institute, Indian Council of Medical Research (ICMR), "We never thought that HIV would ever visit India and take us on. At that time HIV was considered to be a disease of the western world and we had nothing to do with it. But slowly with more and more cases testing positive for the virus, it became a grave concern for us too."

Today with an estimated 23.9 lakh HIV infections (of which 39% are females and 4.4% are children) India is home to the second largest population of people living with HIV - an epidemic which is concentrated in high risk populations such as sex workers and their clients, men who have sex with men, transgenders, and injecting drug users.

AIDS is a unique pandemic that knows no geographical bindings. The HIV virus survives till the death of the host. The virus attaches itself to the host CD4 cells that aid its replication. The life cycle of the virus can be as short as about 1.5 days from viral entry into a cell, through replication, assembly, and release of additional viruses, to infection of other cells. Its short life-cycle and high error rate cause the virus to mutate very rapidly, resulting in a high genetic variability of HIV. By the time it is recognized it has already covered 5 pathways, infecting and damaging more and more CD4 cells in the process. The fewer is the number of healthy CD4 cells, the weaker is the immune system, making the person more vulnerable to numerous infections.

The 20 years period from 1986 to 2006 saw the development of safe and effective therapeutic agents which could block each known stage in HIV replication in the human lymphocyte. By late 1986 clinical tests showed that Azido-thymidine (AZT), which had been developed in the 1960s as an anti-cancer agent, slowed the progress of HIV in humans, making AZT the first approved drug treatment for HIV and AIDS. By 2000 the triple drug cocktail had been developed which was the most exciting thing that happened for HIV treatment. Combinations of anti retrovirals create multiple obstacles to HIV replication to keep the number of offspring low and reduce the possibility of a superior mutation. If a mutation that conveys resistance to one of the drugs being taken arises, the other drugs continue to suppress reproduction of that mutation. Combinations usually comprise two nucleoside-analogue RTIs and one non-nucleoside-analogue RTI or protease inhibitor.

India has played a significant role in combating the disease by way of manufacturing generic drugs used in treatment of HIV, thus bringing down the cost of medicines to affordable levels. Today it supplies 85% of the low cost HIV drugs to the developing world. Also, over the past few years we have seen a lot of advocacy for HIV control programs at different levels - NGOs, government and networks of people living with the disease themselves. In 1992 the National AIDS Control Organization (NACO) was created. This helped in improving the understanding of the complex HIV epidemic in India, with the focus shifting from raising awareness to behaviour changes; from a nationalized response to a more decentralized one. The results of these combined efforts are there for everyone to see. The estimated number of new annual HIV infections has declined by more than 50% over the past decade. India had approximately 1.2 lakh new HIV infections in 2009 as compared to 2.7 lakh in 2008. The trend of annual AIDS deaths is also showing a steady decline since the roll out of free ART programme in India in 2004.

Dr Paranjape feels that there are three major impediments in controlling the disease today:

(i) not having right strategies in place, for reaching most at risk populations, like unorganized female sex workers, injecting drug users, and men having sex with men. Although homosexuality has been de criminalized by law and is gradually being accepted by society, we have not been able to reach them fully. Also those of them who are married are potential threats for transmitting the virus to their wives. So to reach this population is still a major challenge.
(ii) The second challenge is to get everybody under the umbrella of medical care. We still have a situation where from the integrated counselling and testing centre (ICTC) to the time when the patient goes for anti retroviral therapy (ART), there are a lot of missed opportunities, which have to be plugged in.
(iii) Despite huge amount of investments that have rightly gone into research, we still depend upon prevention methods based on behavioural change aspects which are in our hands. We do not have vaccines, microbicides, or any other clinical preventive measures. We only have condom use and behaviour change. A close watch has to be kept on drug resistance too which could pose a great danger, more so as the number of patients on ART goes on increasing (today we have more than 400,000 people on ART and the number is likely to go up). Surveillance for drug resistance and surveillance for recombinant virus is the need of today.

According to Dr Atmaram Bandivdekar, Scientist at the National Institute for Research in Reproductive Health, Mumbai, "There are many issues we still need to understand as to how HIV can infect. Till now people believed that CD4 is the only receptor responsible for HIV binding. But the spermatozoa or vaginal epithelial cells do not have CD4 receptor and still HIV binds to them. We have identified this receptor which is different from CD4. The mechanism of HIV binding to this receptor is different, and so there is a revised need for prevention technology. We are getting some encouraging results in the field of microbicides. But it is too early to say as to when we will have one. The HIV virus is continuously mutating, and in the same person there could be a mixture of different isolates – in blood, semen or in other body fluids also. Hence it is difficult to control the virus and prevention is not easy. As clinical prevention strategies right now are not very effective, we can only socially educate the people to prevent unprotected sex. Multiple sex partners increase the risk of exposure to multiple viruses, and live in relationships can also be a problem area."

One must remember that in India unprotected sex (87.4% heterosexual and 1.3% homosexual) is the major route of transmission of the virus, followed by parent to child transmission (5.4%), infected needles/syringes (1.7%) and use of infected blood and blood products (1%).

According to Dr Dilip Mathai, Professor and Head, Department of Medicine, Christian Medical College (CMC), Vellore: "I do not believe that anyone should die of HIV any longer. The only two deterrents can be - not taking medicines and not knowing their HIV positive status. The problem is that people do not want to be tested, even though treatment is available and lifelong management of the disease is possible. In India we still have a big social problem of stigma/discrimination. This is earth shattering for me. In 2006 I had one ART testing centre and 3010 patients voluntarily tested. I put 3 more centres and now I find only a 1060 people tested. Is it because of poor counselling?"

So it is not only availability of drugs, but proper counselling which plays a very important role in the management of HIV. In the absence of any medicines to cure the disease, good counselling is imperative to ensure treatment adherence and compliance. Doctors can diagnose and treat, but it is the counsellors who are in constant personal touch with the patient. Counselling should not be for the patient alone but stigma and other societal issues need to be addressed too. Very often, due to social stigma people do not come forward to avail of the free govt treatment. Adolescent education on this issue is very important. This is the critical age where people need to be well informed about the perils of unsafe sex. As of now, we have a dearth of qualified counsellors.

All said and done, we have indeed come a long way from those days when the disease was nothing short of a death sentence. Today the situation is very optimistic and we see the HIV epidemic coming under control, though eradication is still a long dream with about 1.72 lakh people dying of AIDS related causes in 2009 in India. Yet, one can now think of HIV just as a chronic disease, like diabetes, heart disease, hypertension, which can be controlled by taking medicines lifelong. Quality as well as longevity of life has increased. The scores of PLHIV I have come in contact with, are more lively, healthy and cheerful than their negative counterparts.

But a lot more needs to be achieved. All eligible patients have to be put on ART, and parent to child transmission has to be brought down to zero. We must strengthen, and not cut down on methods, to ensure that we do not lose on whatever success we have achieved. Also there should be no relaxation on funding by national and international agencies. Because if we become complacent now we are likely to lose the gains made in the past few years.

Shobha Shukla - CNS

(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)